Test - GLOM Outpatient Services

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GLOM Global
GLOM ARF
GLOM THP
GLOM SAP
GLOM OPS

GLOM Global
GLOM ARF
GLOM THP
GLOM SAP
GLOM OPS

“To Give people from all backgrounds access to resources and supportive mental health services that will enhance the lives of the underserved”

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Test Form

Step 1 of 4

25%

Client Name(Required)

First Last

County Med Record#(Required)

DOB(Required)

MM slash DD slash YYYY

Age(Required)

Gender(Required)

SS#

Preferred Language(Required)

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Name of Housing/Type

Status

Licensed

Unlicensed

Length of Stay

House Administrator/Contact Personnel?(Required)

Phone(Required)

Referral Date(Required)

MM slash DD slash YYYY

Referring Staff Member(Required)

Referring Program(Required)

Phone(Required)

Psychiatrist

Phone

Address

Street Address Address Line 2 City State ZIP Code

Primary Care Physician

Phone

Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact Person

Emergency Contact Phone

Relationship to Emergency Contact

Best contact time

Hours

:

Minutes

AM/PM

Current Psychiatric Diagnosis(Required)

Click "+" to add more

Current Medical Diagnosis

Column 1

Column 2

Column 3

Click "+" to add more

Current Medications and dosage

Check all applicable

Insurance

Insurance Type(Required)

Medi-Cal

Medicare

Other

None

County

Other

Legal Status(Required)

AB109

PC290

Forensics

Veteran

Probation

Formal

Informal

Ward or Dependent of the Court

Conserved

Representative

Conserved

Unknown

(check all applicable):

Probation officer name

Contact Info

Child Welfare Service Provider

Contact Info

Conservator

Contact Info

Payee

Contact Info

Other

Source of Income

Income Type(Required)

GA

SSI

SSDI

Cal-Fresh

VA Benefits

Wages from Employment

Other

None

Current Employer

Other

History of Self-injury/Suicide(Required)

Yes

No

Unknown

Please explain

History of Danger to Others(Required)

Yes

No

Unknown

Please explain

History of Substance Use(Required)

Yes

No

Unknown

Please explain

Does the client have a history of, or currently at risk for homelessness?

Yes

No

Please describe

Please describe the client’s current social support system, including friends, family (including any children and their location), involvement in community activities

Please describe the level of services currently being provided to the client, and/or strategies that have been helpful to that person’s recovery. Please also describe any strategies that have not been successful

Are there any cultural, religious, or spiritual considerations the individual wishes to be incorporated in services?

Yes

No

Unknown

Explain

Has the referral been discussed with the client being referred?(Required)

Yes

No

Please describe any input, requests, or concerns the individual has

Has a recent assessment been completed for client?(Required)

Yes

No

If yes, please attach to application

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 5 MB, Max. files: 5.

Specific Services Requested(Required)

Assessment/ Goal Setting

Individual Psychotherapy

Case Management

Counseling

Med Management

Transportation

Group Therapy

Employment/Vocational Support

Group Rehab

Psycho education/Life skills

(Check all that apply)

Digital File Upload

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 20 MB.

Here is the list of documents requested for upload.

Transitional Housing Referral Form
Medical Checklist or Physician’s Report (within 1 year)
List of all Current Medications (medical and psychiatric) – attach MARS
TB Skin Test or Chest X-Ray Clearance (must be within 1-year, same day testing applicable)
Medi-Cal Printout (if applicable) 6. ☐ Recent MD Progress notes (if applicable
Recent CM Progress Notes (if applicable)
If coming from a medical or psychiatric hospital, discharge summary
Most Recent Assessment (if applicable)
Recent Crisis Screening (if applicable)
Face Sheet (if applicable)
ROI

Service Provisions

Mobile Therapy
Case Management Services
Clinical Services
Medical Services
Psychiatric Services

About

Our History
Testimonials
HIPAA Notice of Privacy Practices

Contact

3131 Independence Drive Livermore, CA 94551
(925) 334-7185 Phone
(925) 336‐3148 Fax
info@glom-ops.org

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